HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuthy, R. A. Articles by Qian, F. Search for Related Content PubMed PubMed Citation Articles by Kuthy, R. A. Articles by Qian, F.

Students’ Comfort Level in Treating Vulnerable Populations and Future Willingness to Treat: Results Prior to Extramural Participation

Key words: attitude of health personnel, student comfort, extramural, willingness to treat, frail elderly, dental care for disabled

Submitted for publication 07/11/05; accepted 08/30/05

	Abstract

Top Abstract Methods Results Discussion References

 
This study analyzed senior dental students’ perceptions prior to extramural rotations for comfort and future willingness to treat patients with special needs and other vulnerable groups. The sample included 690 University of Iowa senior dental students who graduated from 1992 through 2004. These students completed a questionnaire concerning twelve vulnerable population groups. Logistic regression models were performed, using student comfort and future willingness to treat each group as the dependent variable. There was a wide percentage of range of comfort with these groups, yet there was no individual group that more than 60 percent of these students were willing to treat in their future practices. Generally, prior experience with the group had a positive impact on comfort level. When gender was included in the regression models, male students were more likely to express comfort. In all instances except one, experience had a positive influence on perceived future willingness to treat the associated group. However, younger graduates had a greater willingness to treat. When controlling for other variables within the future willingness to treat models, comfort was statistically significant only for HIV+/AIDS and non-English speaking groups. This study provides insight about comfort with and perceived future willingness to treat special needs and other vulnerable patient groups.

Moreover, many dental schools have limited students’ clinical exposure to special needs and other vulnerable populations because novice students are still learning to perfect procedural techniques. The current dental education system places more emphasis on developing treatment precision for a limited number of healthy adults and children than providing care for individuals with more complex diseases or conditions. However, the Commission on Dental Accreditation recently revised its standards so that dental graduates must at least be competent in "assessing the treatment needs of patients with special needs."¹ It will be a challenge to prepare the next generation of practitioners to meet the oral health needs of such a diverse and large population of special needs patients, which is growing substantially.²

While extramural programs have been integrated into the curriculum program at many dental schools for a number of years,³ these experiences vary among institutions.⁴ Furthermore, the sparse literature relating to the effectiveness of these programs in addressing special needs populations is generally limited to student perceptions subsequent to these experiences and is either quite global^5–8 or very specific to one group of special needs patients.^9–10 An overarching goal of extramural programs is to provide essential experiences that help students develop a broad understanding of the responsibilities they will have as dental professionals. This is achieved by providing students with opportunities to observe and work with diverse social, cultural, and age groups and those who have medical, dental, personal, and other problems that are not often encountered within the predoctoral curriculum of dental schools.

Dental students, like other individuals, enter into situations with specific beliefs and values that could have an impact on how they practice and influence what they learn. The purpose of this study was to compare students’ perception of comfort in treating selective special needs and other vulnerable groups prior to starting extramural rotations. Moreover, we explored whether gender, prior experience with each population group, and comfort in treating this population have an impact on students’ anticipated willingness to treat these population groups once they graduate. This study is the first of three research phases about perceptions with comfort and willingness to treat these patient groups. Related studies will be reported, using similar analytic techniques, about students’ comfort and future willingness to treat these groups immediately after the extramural rotations and then again after they graduate from dental school.

	Methods

Top Abstract Methods Results Discussion References

 
In 1969, the University of Iowa initiated a voluntary extramural program, focusing on a private practice, preceptor model.¹¹ Soon thereafter, the program became mandatory, and within the next decade it shifted focus from the private sector to a more community-based philosophy. Senior dental students now participate in two consecutive, five-week extramural rotations under the administration of the Department of Preventive and Community Dentistry. Students are matched with several in- and out-of-state affiliated programs. Approximately one-fourth of each class rotates to these extramural sites at any one time during the academic year.

A total of 690 senior dental students who graduated from 1992 through 2004 were included in this analysis. Senior students participated in an orientation session approximately two weeks prior to their first extramural assignment. At that seminar the extramural course director discussed program goals and objectives, provided a general overview about the specific sites and the clientele served, reviewed logistical information about sites, and addressed students’ questions and concerns. During the orientation session students completed a questionnaire that requested the following: gender and race; the names of their two extramural program assignments; experience in dealing with twelve different vulnerable populations; self-assessment of their comfort with treating these groups; and whether they would be willing to treat these groups once they graduate from dental school. The twelve special needs and vulnerable patient groups, in the order that they appeared on the survey, were: low income; frail elderly; homebound; medically complex; mentally compromised; homeless; drug users; other ethnic groups; Title XIX eligible (Medicaid); HIV+/AIDS; jailed; and non-English speaking. Students’ level of comfort was measured using a five-point Likert-style scale (5=no problem; 4=OK; 3=some concern; 2=rather not; and 1=will not treat). Questions concerning students’ prior patient experience with each of the groups and their anticipated willingness to treat each group beyond graduation were categorized dichotomously (Yes/No).

Data from this thirteen-year period were entered into an Excel spreadsheet and then imported to SAS version 9 for analysis. This project was reviewed and approved by the University of Iowa Institutional Review Board.

Skewness of univariate frequency statistics determined that, for statistical analyses, the comfort level variable for each population group needed to be collapsed into a dichotomous variable that consisted of YES, comfortable (which represented no problem and OK) or NO, not completely comfortable (which represented some concern, rather not, and will not treat). This latter group was combined because there were insufficient numbers in each of the three categories to undergo meaningful statistical testing. Moreover, the year since graduation was divided into two categories—less than or equal to five years since graduation (younger) and greater than five years (older)—to simplify the statistical interpretation.

Comfort in treating and future willingness to treat each of the twelve groups were initially compared, using bivariate analysis with either Chi-square or Fisher Exact statistic, for gender, years since graduation, and students’ experience with each group. Logistic regression models were then created for each group when bivariate results demonstrated a p-value less than or equal to 0.1, a liberal value for initial entry into the regression model. If there were no bivariate findings within that population group who met the criterion, then no regression model was developed. Variables were entered into the model using stepwise regression, followed by forward and backward selection methods (p<0.05) to determine the best statistical approach. The possibility of two-way interactions was examined.

	Results

Top Abstract Methods Results Discussion References

 
Of the 690 senior dental students, 68.2 percent were male and 51.9 percent were in the older (i.e., graduated between 1992 and 1998) of the two cohorts. Table 1 displays the mean and median scores for comfort with treating each group and the percentage of students who were comfortable, had any experience, and willing to treat these patients subsequent to graduation. Mean comfort ratings ranged from a low of 3.6 (HIV+/AIDS) to a high of 4.8 (other ethnic group) on a 5-point scale. When the comfort variable was collapsed into a dichotomous category (i.e., no problem and OK versus some concern, rather not, and will not treat), then the range of students who were comfortable in treating the groups ranged from a low of 47.4 percent (HIV+/AIDS) to 98.4 percent (other ethnic group). There were four groups (homebound, homeless, HIV+/AIDS, and jailed) for which less than one-quarter of the students had some prior experience. Conversely, there was only one group (Title XIX [Medicaid]) in which more than three-quarters of the students had some prior experience. For each patient group, less than 60 percent of the students indicated that they would be willing to treat this group in the future. Only frail elderly and medically complex had a higher percentage of students indicating that they will treat these groups in the future when compared with the percentage of students who had prior patient experience with the same group.

Five other regression models (medically complex, mentally compromised, drug user, jailed, and non-English speaking) were statistically significant for gender and students’ prior experience. In each model, male students were more likely to express comfort with the affected population, with a range between 1.66 times (non-English speaking) to 3.69 times more likely (jailed). With the exception of comfort with medically complex patients (at 1.48 times more likely) and mentally compromised (at 10.39 times more likely), those with some prior experience had a similar magnitude (2.19 to 2.51 times more likely) to be comfortable with drug users, jailed, and non-English speaking patients.

Mentally compromised patients had the only statistical interaction (i.e., prior experience by gender) among all of the comfort level regression models. There were significant associations between comfort and prior experience for both males (p=0.0034) and females (p<0.0001); however, male students who had no prior experience in treating mentally compromised patients had a higher percentage for comfort (52.3 percent) than did female students who had no experience (36.5 percent).

Only jailed patients failed to achieve the statistical criterion for inclusion in the future willingness to treat regression model. The common predictor variable for each of the other regression models was any prior experience with the population group (Table 5). Students were more likely to be willing to treat frail elderly (2.78 times), homebound (4.65 times), homeless (2.74 times), or drug users (2.58 times) if they had any prior experience with the group compared with those without any experience.

Four other regression models demonstrated statistically significant results for both prior experience and graduation year. When experience with population groups is combined with the other predictor variables in the regression models, there are additional benefits. More recent graduates were 2.93, 3.00, 1.66, and 1.70 times more likely and those with prior experience were 4.03, 3.20, 2.01, and 2.69 times more likely to be willing to treat low-income, medically complex, mentally compromised, and other ethnic group patients, respectively, than the more distant graduates and those without experience.

Regression models for HIV+/AIDS and non-English speaking patients met the statistical criteria for inclusion of student comfort as a predictor variable. In both instances, there was a more positive willingness to treat the groups based on comfort level with these groups. Gender, however, only entered into the model for Title XIX patients. Female students were 1.44 times more likely than their male counterparts to see Title XIX patients in their future practices, while controlling for graduation year and prior experience.

Two future willingness-to-treat regression models contained statistical associations for interaction. For the younger student cohort there was no association between willingness to treat low-income patients and having experience in treating them (p=0.0723), whereas there was a positive association for the older student cohort (p<0.0001) with prior experience in their willingness to treat low-income patients. Similarly, the younger student cohort did not demonstrate a statistical association between willingness to treat medically complex patients and having experience in treating them (p=0.4109); however, there was a statistically significant, positive association for the older student cohort (p<0.0001) with prior experience in their willingness to treat medically complex patients.

	Discussion

Top Abstract Methods Results Discussion References

 
Twenty-four regression models, each representing either comfort with or future willingness to treat specific special needs or other vulnerable populations, were developed for understanding dental students’ perceptions prior to their extramural rotations.

With four exceptions, experience in treating various populations appeared to have a positive and significant influence for comfort level with these groups. These exceptions were for low-income, homeless, other ethnic group, and Medicaid, which were the groups with the highest level of student comfort (Table 1). When there was a statistically significant difference in the comfort regression models (medically complex, mentally compromised, drug user, jailed, and non-English speaking), males had a higher comfort level prior to the extramural rotations. There were only two regression models that included graduation year as a predictor for student comfort. Controlling for other predictor variables, newer graduates were more comfortable with HIV+/AIDs, whereas the older cohort perceived more comfort with homebound patients.

Perceived future willingness to treat the groups demonstrated some similarities and differences as compared to the perceived comfort statistical models. Except for the incarcerated, students expressed a greater willingness to treat each population group if they had previous experience. Unlike the comfort models, gender only appears in one final model. When holding years since graduation and experience constant, females were 1.44 times more likely to express willingness to treat Title XIX patients in the future. The younger cohort also expressed a greater willingness to treat several of these groups, including low-income, medically complex, mentally compromised, other ethnic groups, Title XIX, and non-English speaking patients. Comfort level with the population groups was only predictive for future willingness to treat with two groups: HIV+/AIDS and non-English speaking.

Several methods have been used to determine health professional students’ attitudes toward traditionally underserved or high-risk groups, such as elderly,^12–16 low income or poor,^17–18 HIV+/AIDS,^19–23 disabled or handicapped,^24–28 mental retardation,¹⁰ homeless,²⁹ or minorities.³⁰ None of these studies provides a complete picture about the constellation of thought and reasoning in determining attitudes. However, educators realize that students bring preconceived attitudes to their extramural experiences, which may be based on purposefully constructed knowledge-based information, acquired indirectly through influences of faculty or other students ("hidden curriculum"), or developed as a result of home environment. These attitudes can exist for a myriad of reasons, although we commonly explore demographic and social influences. While negative attitudes may be very hard to reverse, there are some indications that for at least one disease, HIV+/AIDS, there has been a societal shift in perspectives about care for individuals with HIV+/AIDS.³¹

An objective of extramural programs is to sensitize students to social and cultural factors affecting patient care.³ Educators are hopeful that there will be a substantive positive change in comfort in treating traditionally underserved populations, if it doesn’t already exist. Ultimately, favorable attitudes should convert this comfort into the students’ future willingness to incorporate some of these population groups into their practices. Unfortunately, there is evidence to suggest that the educational system tends to increase cynicism and to decrease humanism and empathy.²⁶ Regardless, efforts to measure attitudes should be initiated and monitored so that progress can be determined concerning any relationship between attitude and behavior of the professional.³²

These findings contribute to our understanding of students’ attitudes about providing care for twelve specific vulnerable and special needs groups. These groups represent patients who are not considered the norm for most private practices and who may not often be encountered by students in dental school clinics. While one would have suspected that prior experience would influence comfort level or future willingness to treat many of these groups, this nonetheless provides empirical findings to support that claim. This is especially true for students who probably have limited exposure to many of these groups.

Possible reasons for why males may feel more comfortable but are not any more likely to express a future willingness to treat these population groups than females are likely to be multifactorial and require further exploration. There are undoubtedly some self-selection criteria that foster the decision to enter dentistry and, thus, may have some influence on students’ comfort or patient selectivity. However, there may be other underlying gender issues that influence patient care attitudes and practice characteristics.³³ Future researchers need to explore the influence of gender upon patient care attitudes in more depth and determine what impact it might have as more female dentists enter the profession.

There are several limitations to these findings. It was up to students to make their own decision about the definitions for "comfort" and "willingness"; thus, there may be latitude in how individuals interpreted these terms. Also, the perceived levels of comfort and willingness to treat these populations may or may not be representative of more fundamental attitudinal issues relating to any or all of these patient population groups. Better scales for investigating the relationship between comfort and willingness to treat need to be implemented in dental education. However, these findings provide some needed insight about core attitudinal issues relating to access to care for many underserved groups.

In conclusion, this study provides baseline information about students’ comfort level for treating various special needs and vulnerable populations prior to extramural rotations. Moreover, this study provides perceptions of these students’ willingness to treat these populations beyond dental school. The findings have implications for curricular development, particularly as students encounter a more diverse population within and external to the dental school environment. There should be course objectives that adequately prepare students so that they better appreciate the populations whom they serve.

	Footnotes

 
Dr. Kuthy is Professor and Chairperson, Department of Preventive and Community Dentistry; Dr. McQuistan is Assistant Professor, Department of Preventive and Community Dentistry; Ms. Riniker is a fourth-year dental student; Dr. Heller was Assistant Professor until his death; and Dr. Qian is Adjunct Assistant Professor—all at the University of Iowa College of Dentistry. Direct correspondence to Dr. Raymond A. Kuthy, N336 DSB, University of Iowa College of Dentistry, Iowa City, IA 52242-1010; 319-335-7201 phone; 319-335-7187 fax; raymond-kuthy{at}uiowa.edu.

This project was supported, in part, by NIH/NIDCR T32 DE14678 and Dows Student Research Award, University of Iowa College of Dentistry.

	REFERENCES

Top Abstract Methods Results Discussion References

 

1. Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, July 30, 2004.
2. Waldman HB, Fenton SJ, Perlman SP, Cinotti DA. Preparing dental graduates to provide care to individuals with special needs. J Dent Educ 2005;69(2):249–54.[Abstract/Free Full Text]
3. Born DO, DiAngelis AJ. Extramural education programs in the ‘80s. J Dent Educ 1986;50(12):731–3.[Medline]
4. Ayers CS, Abrams RA, McCunniff MD, Goldstein BR. A comparison of private and public dental students’ perceptions of extramural programming. J Dent Educ 2003; 67(4):412–7.[Abstract]
5. Gardiner JF, Lotzkar S. A survey of extramural experiences for dental students. J Dent Educ 1975;39(8):530–4.[Abstract]
6. Berg R, Berkey DB. University of Colorado School of Dentistry’s advanced clinical training and service program. J Dent Educ 1999;63(12):938–43.[Medline]
7. Jacobson JJ, Kotowicz WE, Turner DF. University of Michigan school of dentistry’s community practice 857. J Dent Educ 1999;63(12):964–8.[Medline]
8. DeCastro JE, Matheson PB, Panagakos FS, Stewart DC, Feldman CA. Alumni perspectives on community-based and traditional curricula. J Dent Educ 2003;67(4):418–26.[Abstract]
9. Block MJ, Walken JW. Effect of an extramural program on student attitude toward dental care for the mentally retarded. J Dent Educ 1980;44(3):158–61.[Medline]
10. Wolff AJ, Waldman HB, Milano M, Perlman SP. Dental students’ experiences with and attitudes toward people with mental retardation. J Am Dent Assoc 2004; 135(3):353–7.[Abstract/Free Full Text]
11. Phair WP. The dental preceptorship program. Iowa Dent Bull 1969;3(2):8–13.[Medline]
12. Paris BEC, Gold G, Taylor B, Fields SD, Mulvihill MN, Capello C, deBeer K. First year medical student attitudes toward the elderly: a comparison of years 1986, 1991, and 1994. Gerontol Geriatr Educ 1997;18(1):13–22.
13. Woo JKH, Ghorayeb SH, Lee CK, Sangha H, Richter S. Effect of patient socioeconomic status on perceptions of first- and second-year medical students. Can Med Assoc J 2004;170(13):1915–9.[Abstract/Free Full Text]
14. Wood GJ, Mulligan R. Cross-sectional comparison of dental students’ knowledge and attitudes before geriatric training, 1984–1999. J Dent Educ 2000;64(11):763–71.[Abstract]
15. Pyle MA, Jasinevicius TR, Sheehan R. Dental student perceptions of the elderly: measuring negative perceptions with projective tests. Spec Care Dent 1999;19(1):40–6.
16. Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. J Am Geriatr Soc 1995;43(12):1430–6.[Medline]
17. Atherton CR, Gemmel RJ, Haagenstad S, Holt DJ, Jensen LA, O’Hara DF, Rehner TA. Measuring attitudes toward poverty: a new scale. Soc Work Res Abstracts 1993; 29(4):28–30.
18. Price JH, Desmond SM, Snyder FF, Kimmel SR. Perceptions of family practice residents regarding health and poor patients. J Fam Pract 1988;27(6):615–21.[Medline]
19. Carter DD. Using attitude surveys in medical ethics research and teaching: the example of undergraduate willingness to treat HIV-infected patients. Med Educ 1998;32(2):121–6.[Medline]
20. Cohen LA, Romberg E, Grace E. A revisitation of dental students’ attitudes toward individuals with AIDS. J Dent Educ 2000;64(4):298–301.[Medline]
21. Currey CJ, Johnson M, Ogden B. Willingness of health professions students to treat patients with AIDS. Acad Med 1990;65(7):427–34.[Medline]
22. Driscoll JM, Hoffman MA. Exploring attitudes of white dental students regarding willingness to treat people with HIV. J Dent Educ 1997;61(9):717–26.[Abstract]
23. Ladany N, Stern M, Inman AF. Medical students’ perceptions and willingness to treat patients who are HIV infected. J Appl Soc Psychol 1998;28(12):1031–50.
24. Loiacono C, Muzzin KB, Guo IY. Dental hygiene students’ attitudes toward treating individuals with disabilities. Probe 1996;30(6):220–4.[Medline]
25. Paris MJ. Attitudes of medical students and health-care professionals toward people with disabilities. Arch Phys Med Rehabil 1993;74(8):818–25.[Medline]
26. Potts MK, Katz BP, Brandt KD. Sex differences in medical student and housestaff attitudes toward the handicapped. J Am Med Womens Assoc 1986;41(5):156–9.[Medline]
27. Tervo RC, Azuma S, Palmer G, Redinius P. Medical students’ attitudes toward persons with disability: a comparative study. Arch Phys Med Rehabil 2002;83(11):1537–42.[Medline]
28. Tervo RC, Palmer G, Redinius P. Health professional student attitudes towards people with disability. Clin Rehabil 2004;18(8):908–15.[Abstract/Free Full Text]
29. Masson N, Lester H. The attitudes of medical students towards homeless people: does medical school make a difference? Med Educ 2003;37(10):869–72.[Medline]
30. Pico E, Wimbley M, Wells KB. First-year students’ expectations of interacting with minority patients and colleagues. Acad Med 1992;67(6):411–2.[Medline]
31. Cohen LA, Romberg E, Grace E. Revisiting the attitudes of dental faculty toward individuals with AIDS. J Dent Educ 2001;65(3):249–52.[Medline]
32. Brown G, Manogue M, Rohlin M. Assessing attitudes in dental education: is it worthwhile? Br Dent J 2002; 193(12):703–7.[Medline]
33. Scholle SH, Gardiner W, Harman J, Madlon-Kay DJ, Pascoe J, Kelleher K. Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment. Med Care 2001;39(1):26–38.[Medline]

This article has been cited by other articles:

				C. Kunzel, S. Kaur, K. Ahluwalia, T. Darlington, P. Kularatne, S. Burkett, D. Hou, M. Sanogo, M. Murrman, and B. Edelstein Considering Theory-Based Reflection in the Service-Learning Training of Advanced Education in General Dentistry (AEGD) Residents J Dent Educ., January 1, 2010; 74(1): 58 - 64. [Abstract] [Full Text] [PDF]

				M. Sadeghi and H. Hakimi Iranian Dental Students' Knowledge of and Attitudes Towards HIV/AIDS Patients J Dent Educ., June 1, 2009; 73(6): 740 - 745. [Abstract] [Full Text] [PDF]

				D. C. Carreon, P. L. Davidson, and R. M. Andersen The Evaluation Framework for the Dental Pipeline Program with Literature Review J Dent Educ., February 1, 2009; 73(2_suppl): S23 - 36. [Full Text] [PDF]

				A. Thind, K. A. Atchison, R. M. Andersen, T. T. Nakazono, and J. J. Gutierrez Reforming Dental Education: Faculty Members' Perceptions on the Continuation of Pipeline Program Changes J Dent Educ., December 1, 2008; 72(12): 1472 - 1480. [Abstract] [Full Text] [PDF]

				S. Dharamsi, D. D. Pratt, and M. I. MacEntee How Dentists Account for Social Responsibility: Economic Imperatives and Professional Obligations J Dent Educ., December 1, 2007; 71(12): 1583 - 1592. [Abstract] [Full Text] [PDF]

				D. W. Chambers, N. A. Nadershahi, and H. Chi The Origins of Fear of Occupational Exposure in the Clinical Dental Setting J Dent Educ., February 1, 2007; 71(2): 242 - 248. [Abstract] [Full Text] [PDF]

				E. J. Rohn, A. Sankar, D. C. Hoelscher, M. Luborsky, and M. H. Parise How Do Social-Psychological Concerns Impede the Delivery of Care to People with HIV? Issues for Dental Education. J Dent Educ., October 1, 2006; 70(10): 1038 - 1042. [Abstract] [Full Text] [PDF]

				A. J. Wood, N. A. Nadershahi, R. E. Fredekind, E. J. Cuny, and D. W. Chambers Student occupational exposure incidence: perception versus reality. J Dent Educ., October 1, 2006; 70(10): 1081 - 1088. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kuthy, R. A. Articles by Qian, F. Search for Related Content PubMed PubMed Citation Articles by Kuthy, R. A. Articles by Qian, F.